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Gold

Silver

Bronze

Bronze HSA1

Catastrophic2

Individual Deductible & Out-of-Pocket

Single Type

Family Type

Participant deductible (in network) $1,000 $2,500 $5,500 $3,500 NA $6,350
Participant deductible (out of network) $3,500 $5,000 $8,000 $6,000 NA $8,850
Maximum participant out-of-pocket
(in network)
(deductible & coinsurance)
$6,350 $6,350 $6,350 $6,350 NA $6,350
Maximum participant out-of-pocket
(out of network)
(deductible & coinsurance)
$12,700 $12,700 $12,700 $12,700 NA $12,700

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Family Deductible & Out-of-Pocket

Family deductible (in network) $2,000 $5,000 $11,000 NA $6,000 $12,700
Family deductible (out of network) $7,000 $10,000 $15,000 NA $12,000 $17,700
Maximum family out-of-pocket
(in network)
(deductible & coinsurance)
$12,700 $12,700 $12,700 NA $12,700 $12,700
Maximum family out-of-pocket
(out of network)
(deductible & coinsurance)
$25,400 $25,400 $25,400 NA $25,400 $25,400

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Coinsurance

Blue Cross Blue Shield of Wyoming pays 80% 75% 50% 50% 50% 50%
Participant pays (coinsurance) 20% 25% 50% 50% 50% 50%

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Preventive care

Paid at 100% of maximum allowable amount at appropriate intervals when services are rendered by a network provider

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Primary care

Copay per visit/per participant $303 $453 $603 Subject to the deductible & coinsurance Subject to the deductible & coinsurance $604

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3 After 6 visits, each subsequent visit is subject to the deductible & coinsurance
4 After 3 visits, each subsequent visit is subject to the deductible & coinsurance
All visits to out of network providers are subject to the deductible & coinsurance

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Prescription Drug Benefits
(retail and mail order)

Generic (copay) $5 $5 $5 Subject to the deductible & coinsurance Subject to the deductible & coinsurance Subject to
the
deductible & coinsurance
Preferred brand (copay) $20 $50 $100
All others Subject to the deductible & coinsurance Subject to the deductible & coinsurance Subject to the deductible & coinsurance

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Twice the copay amount will apply to a 90-day mail order
No coverage for Rx from out of network provider
Summary of Benefits & Coverage (SBC)

Gold

Silver

Bronze

Bronze HSA1

Catastrophic2

 


This outline does not cover all information contained in the benefit document. Limitations and exclusions do exist. This outline is not a contract. For exact benefits and limitations, please request a copy of the benefit document.

1 Important information regarding HSA-Eligible plans: Federal law requires HSA-Eligible plans be either "Single Type" or "Family Type" plans. If you enroll as Two Adult, Adult and Dependent or Family, you will be covered under a "Family Type" plan and must meet the family deductible. If you enroll as a single participant, you will be covered under a "Single Type" plan and must meet the individual deductible.

2 The Catastrophic plan is only available to individuals up to December 31st of the year in which they turn 30 years old. Exceptions are made for those who are eligible for a hardship exemption by applying for the Catastrophic plan online. Each family member on a Catastrophic family plan must meet these requirements.

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